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Rothbarts Foot and PreClinical Clubfoot Deformity

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brian A. Rothbart, May 5, 2023.

  1. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member


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    Weight Bearing CT scans (Silva et al 2020) have demonstrated the rotational distortions (supinatus) within the medial column of the foot that I have been publishing about over the past 20 years. Medial column supinatus is the pathognomonic finding of the PreClinical Clubfoot Deformity and Rothbart's Foot.

    It is now important to discuss how to treat these two abnormal, genetic foot structures that result in debilitating chronic muscle and joint pain.

    Silva TA, Baumfeld DS, et al. 2020. Understanding the Rotational Positioning of the Bones in the Medial Column of the Foot: A Weightbearing CT Analysis. Foot & Ankle Orthopaedics 5(4), Conference AOFAS.​
     
  2. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    The generic proprioceptive insoles sold by the company in Tacoma Washington should only be used when treating Rothbarts Foot. They are counter indicated when treating the PreClinical Clubfoot Deformity.

    In my clinical practice I have treated patients who, after they bought the generic insoles from the Washington state company, their musculoskeletal symptoms increased. In every case, these patients had the PreClinical Clubfoot Deformity.

    I believe this company does not differentiate between these two-foot structures and recommends them for any individual with a medial column supinatus.

    Unfortunately, both abnormal foot structures display medial column supinatus. Hence, the healthcare provider should run the appropriate tests to differentiate which structure is present. And then dispense the appropriate proprioceptive insole.
     
  3. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Another paper demonstrating the supinatus of the talus.

    A 59-year-old patient underwent subtalar fusion, talonavicular joint and first tarsometatarsal joint fusion, medial displacement calcaneal osteotomy, and gastrocnemius recession in an attempt to stabilize the collapse of the medial column of the foot. Unfortunately, they did not address the supinatus of the talus. This resulted in medial column instability, noted in the 6-month PO x-rays.

    3d x-rays taken preop demonstrated talar supinatus.

    This is another example of a severe Rothbart foot deformity.

     
  4. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    This is the proprioceptive insole I designed to treat RFS (Rothbarts Foot Structure). It is counterindicated when treating PCFD (PreClinical Clubfoot Deformity)

    The medial edge has an elevation of 3-9mm (determined at the time of examination). The lateral edge is skived down to 0mm (not simply an elevation).

    Insole RFS.jpg
     
  5. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Attached is a diagram demonstrating the convergence of Rothbarts Foot, PreClinical Clubfoot deformity and Clubfoot deformity.

    A micro wedge is one method of differentiating these embryological foot structures form one another. The exact micro wedge reading delineating a plantar grade foot from Rothbarts foot or Rothbarts foot from PreClinical Clubfoot deformity, are fluid.

    For example, a patient with a micro wedge reading of 16mm could either be a severe Rothbarts foot or a mild PreClinical Clubfoot deformity.

    The diagnosis and intervention for that patient is determined by further clinical tests, e.g., Leg Rotation and Muscle testing, Gait analysis and/or Computer Postural analysis.

    Embryological Foot Types.jpg
     
  6. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    The foot structure you were born with greatly determines your overall health. For example, a plantar grade foot (what you would think of as being a ‘normal’ foot) is linked to having healthy muscles and joints and overall good health. Whereas 3 other foot structures can cause problems ranging from simple foot pain (Morton’s Foot) to chronic pain and other problems throughout the body (Rothbarts Foot and PreClinical Clubfoot Deformity.

    On my patient website I have discussed the differences in structure, function, appearance, prevalence and treatment specific to each of these four distinct foot structures.

    Note: this website page was written nearly 10 years ago, before 3d X-rays were available that could visualize the medial column supinatus. And at that time, I stated it was not possible to visualize mc supinatus on standard 2d X-rays.

    This has all changed! Starting, just a few years ago, medial column supinatus resulting from talar supinatus has been visualized using 3d WBCT.

    Medial column supinatus is the hallmark finding of Rothbarts Foot and PCFD. Healthcare professionals, IMO, must be able to recognize and treat these common embryological foot aberrations.
     
  7. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I have attached a copy of the above webpage (The Plantar Grade Foot vs Morton's Foot, Rothbarts Foot and the PreClinical Clubfoot Deformity) in PDF format, in case you are unable to access my website.
     
  8. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I have provided a link to a publication in Podiatry Review (2010) that differentiates the PreClinical Clubfoot deformity from the Primus Metatarsus Supinatus foot deformity (aka Rothbarts foot).

    • Rothbart BA 2010. The Primus Metatarsus Supinatus (Rothbarts) Foot and the PreClinical Clubfoot Deformity: Brief Introduction. Podiatry Review, Vol. 67(1):
     
  9. Rob Kidd

    Rob Kidd Well-Known Member

    "The Plantar Grade Foot vs. Morton’s Foot, Rothbarts Foot and the PreClinical Clubfoot Deformity (Rev 05/26/2023)" Does not explain where it was published (that is: which refereed journal), and what the referee process was. I accept that the referees are usually anonymous, but you should be able to report upon the process. Perhaps you cannot; I am not surprised. Who normally reviews your material? As I said, I know that there is a degree of anonymity, but notwithstanding, one normally has a good idea. For instance, I know that a fair few of mine have been reviewed by Professor Bernard Wood. (ex of UK, more recently in DC)
     
  10. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    That paper was not published. It appeared on my patient website. I included it here because it gives a brief description of the differences between the 4-foot structures.
     
  11. Rob Kidd

    Rob Kidd Well-Known Member

    In which case it has no academic value. Yes, none.
     
  12. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    That is simply your opinion, no more, no less.

    Have a good day.
     
  13. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    If what you suggest is true, namely any discussion not published in a peer review journal would have (in your opinion) no academic value, that would mean a majority of the discussions on this forum would have no academic value.

    Rob, I must tell you, I adamantly disagree. I have found a great deal of relevant discussions on this forum that have not been published in a peer review journal.
     
  14. scotfoot

    scotfoot Well-Known Member

    Interesting point of view .
    If you are saying unsupported biomechanical speculation has no academic value then I can understand where you are coming from.
    If you are saying that anything that has not appeared in a peer reviewed journal is of any academic value then that would be shocking. Harvard University has laid out how blog sites should be referenced if research papers draw on their content.
     
  15. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Exactly!

    Implying that any information presented on a website has no academic weight is, IMO, specious.
     
  16. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Over 1200 reads on this thread. Has anyone used the postural control insoles to treat RFS (5 cases or more)? If so, what has been your experiences?
     
  17. James X

    James X Welcome New Poster

    Hi all, I'm a patient with self diagnosed "Rothbart's Foot". (Don't attack me yet, I'm planning to get a CT scan for a proper diagnosis. I also saw a podiatrist, who just said "you are born with it, go get an arch support insole.")

    My case is interesting and may offer scientific value for this forum, that only my left foot has this problem, my right foot is normal. I'm able to do a lot of comparison of feelings, muscle engagement, stability, etc, between my left and right foot. I'm an advance level alpine skier, and obviously my left foot is preventing me from becoming expert level, so I've spent a lot of effort studying it.

    I'd like to take a balanced view point regarding Prof Rothbart's claims and insole design. I noticed that he was frequently criticized on this forum, from the potentially inappropriate use of the term "proprioception", to the claims of relationship between foot deformity and fertility/facial asymmetry, etc, that his theory is unsubstantiated. I'd like to leave those aside for now, and focus on the foot.

    I want to offer an explanation on why Prof Rothbart's insole works to a certain degree, and why it also has its limitations, based on my own experimentation on my own body.

    Why it works: I want to start off explaining why it's a wedge under first met, rather than a raised flat surface. What I felt is that the pressure sensors under my sesamoid bones needs to felt the ground reaction force, so that my peroneus longus can be activated and maintain the arch. If a flat, raised surface is used, and due to the first ray being a supinated position, only the lateral side of the lateral sesamoid bone is contacting the ground, and I don't feel I have pressure sensors there. So my first ray will still want to roll over to have both of the sesamoid bones being loaded, and thus the foot collapses.

    Why it doesn't work: Due to the wedge being slanted, the first met has a tendency to slide off. I found this type of "bringing ground to the foot" helps only in a more static setting (it does help me activate my glute when doing squat), but has serious limitations in a more dynamic environment, like skiing.

    My opinion is that nothing, except maybe surgery, can make a "Rothbart's foot" function like a normal foot. I sincerely hope I'm wrong though. The reason lies in how the peroneus longus is pulling the first ray to form arches (longitudinal and transverse). The first ray travels in an arc in the frontal plane. In a normal foot, the center of the arch is when the first met is touching the ground, and the peroneus longus can pull and make the medial sesamoid bone dig in and generate more ground reacting force. I have this feeling with my right foot.

    With my left foot however, I felt that my peroneus longus is pulling my first met towards my second met, not the desired arc trajectory that it goes around the second met and create a transverse arch! Also, my anterior tibialis can easily make the first ray even more supinated! If we think deeply in the mechanics of forces, the peroneus longus's direction of pull is not aligned with the first ray's range of motion dictated by the joint surfaces so it has a hard time, whereas the tibialis anterior is much more aligned so it can pull so easily.

    Finally, I think Prof Rothbart deserve the credit of bringing awareness to this type of foot. The boot fitters, the orthopedic doctor, the podiatrist I've consulted all came with a boilerplate solution of prescription arch support, without even thinking about why it collapses in the first place.
     
  18. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Hi James,

    Your observations and comments are well received. Two specific points you mentioned which I would like to comment on:

    1) "Due to the wedge being slanted, the first met has a tendency to slide off." This occurs when the wedge is not configured correctly to the patient´s foot geometry, that is, the the medial elevation in the wedge is too high (excessive for that specific patient). Clinically, This lateral sliding off the insole is clearly visible during the treadmill analysis. Whereas standing, no lateral sliding is observed.

    There is a simple test you can do at home to determine if the wedge is to severe for your foot deformation:

    Stand on your insoles (no shoes) near the wall. Lean into the wall (like the leaning tower of Piza). Then bend your knees (maintaining your lean). If you feel your foot sliding laterally off the insole(s), the medial elevation is too severe for your foot. It needs to be reduced.

    2) Regarding the role the Tibialis and Peroneus muscles have in maintaining ILA integrity, I believe the muscles are secondary in maintaining ILA integrity. Zitzlesperger (1960) wrote an excellent paper describing the link between the STJ axes and pronation/supination. Succinctly, he states in a plantar grade foot, (absence of calcaneal or medial column supinatus) supination crosses the axes of the STJ which structurally locks the forefoot (maintaining ILA stability) whereas pronation uncrosses the STJ axes resulting in the "loose bag of bones" syndrome (ILA collapses).

    Currently, Zitzlesperger is out of favor with many healthcare providers, believing that the muscles are the primary driver in maintaining ILA integrity. My research has been consistent with Zitzlesperger work.

    Zitzlesperger S 1960 the mechanics of the
    foot based on the concept of the skeleton
    as a statically indetermined space
    framework. Clinical Orthopedics 16:
    47–63
     
  19. efuller

    efuller MVP

    Hi James, Welcome to podiatry arena.

    You left out a few of the criticisms of Brian Rothbart.

    He as attacked the science of understanding foot motion. He said discussions of the science gave him a headache.
    https://podiatryarena.com/index.php?threads/occams-razon-or-the-law-of-parsimony.113264/

    He has repeatedly posted here on podiatry arena so that web bots will pick up his terminology, even though he has nothing new to say. He was proud of the fact that he was able to manipulate Chatgpt to quote his definition of gravity drive pronation. The problem with his claiming that this is a valid way of describing why pronation occurs is that the science of what causes motion gives him a headache.

    https://podiatryarena.com/index.php?threads/etiology-of-gravity-drive-pronation.114164/
    See post #3


    He consistently takes concepts that have been discovered before him and then renames him after himself.
    You can compare his insole to one that was patented almost 100 years ago by Morton. https://patents.google.com/patent/US1847973A/en
    He recently wrote that Morton's insole was paper thin and you can see from picture in the above patent it is not. He will give long incoherent reasons of why his think is different.

    There were more criticisms and they can be found by searching Rothbart here on the arena.


    This type of foot was described before (???Professor??? there is another criticism) Rothbart did. His giving another name to something that already exists just confuses the issue. Root et al described a partially compensated varus before Rothbart attached his name to it. You can find those discussions here on the arena.

    Gravity drive is not a valid description of the cause of pronation.
    Gravity drive is not a valid description of the cause of pronation.
    Gravity drive is not a valid description of the cause of pronation.
    Gravity drive is not a valid description of the cause of pronation.
    Gravity drive is not a valid description of the cause of pronation.
    Gravity drive is not a valid description of the cause of pronation.

    If you say it enough times ChatGPT may quote you.
     
  20. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member


    I have published over 50 papers on my research. Choose one and let us open a discussion. I welcome the challenge.
     
  21. efuller

    efuller MVP

    The reason that this sixty year old paper has come into disfavor is that is is contrary to simple engineering principles. The paper only examines compression between the bones and ignores tension forces in the ligaments. One of the first things taught in basic engineering textbooks is that a beam has compression and tension. The foot behaves like a beam. Brian, gets a headache when people talk about forces, but you do need to understand the forces to explain arch collapse as well as normal motion. I

    Another problem with Brian is that he is misquotes the article. The crossing and uncrossing of axes was discussed by Manter and Elftman. That theory of "locks the forefoot and loose bag of bones" was discarded because axes of motion are imaginary lines and imaginary lines cannot lock up a forefoot.
     
  22. efuller

    efuller MVP

    We could choose the one where you said that 95% of people have Rothbart's foot. Oh wait you already agreed that was wrong.
     
  23. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I disagree.
     
  24. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    At one time I believed the incidence of RFS was nearly 95% (based on a skewed sample). Currently (based on a more recent and larger sample size) I estimate over 50% of patients with gravity drive pronation have either the RFS or PCFD.
     
    Last edited: Feb 27, 2024
  25. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Have you published on this? If so, I would be happy to read your research.
     
  26. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    If my memory serves me, Zitzlesperger preceded Manter and Elftman discussion on this subject. Although they were not in total agreement.

    I will have to dig out these publications and compare them, to be certain.
     
    Last edited: Feb 26, 2024
  27. efuller

    efuller MVP

    Refutation of Zitzelberger can be found in any introduction to engineering textbook that can be found in any college bookstore where engineering is taught.

    Refutation of Elftman and Manter was done superbly in
    A kinematical analysis of the tarsal joints. An X-ray photogrammetric study.
    van Langelaan EJ.Acta Orthop Scand Suppl. 1983;204:1-269.
     
  28. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member


    Excellent paper. Langelaan study provides kinematic data on the various tarsal joints, useful for understanding foot and ankle biomechanics. But I do not remember any refutation of Zitzlesperger research.

    Which specific introduction to engineering textbook are you quoting from? Scan the page and post it on this forum.

    Regarding refutation of Elftman and Manter research (arched structure of ILA directly propels the center of mass forward and upward utilizing leverage about the phalanges, with spring-like energy), Sun X, Wanyan Su, et al (2022) disagreed, and I assume, so do you. If I remember correctly, they concluded:
    • Foot mechanics are complex and cannot be accurately represented by simple models.
    • The interactions between the longitudinal arch and Plantar Fascia appear less constrained due to the structural complexity of the feet.
    Xiaole Sun, Wanyan Su et al 2022. Changes of the in vivo kinematics of the human medial longitudinal foot arch, first metatarsophalangeal joint, and the length of plantar fascia in different running patterns. Biomechanics, 29 November. (Volume 10 - 2022 | https://doi.org/10.3389/fbioe.2022.959807)
     
    Last edited: Feb 27, 2024
  29. James X

    James X Welcome New Poster

    Hi Prof Rothbart,

    Thanks for the comments!

    Re 1. I should say that the tendency to slide off the wedge happens in a more active movement, like a lateral push off, or sudden stop (imaging a basket ball player). The friction is not enough in these violent movements.

    Re 2. I haven't read the paper but it sounds like it resonate with my situation. My left foot feels exactly like a loose bag of bones. My right foot only needs minimum effort to lock the bones into a rigid structure.
     
  30. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Have the wedges in your insoles resized to the correct dimensions. That will stop the sliding and make them very useful in you skiing competition.

    Muscles become progressively more engaged in proportion to the degree of gravity drive pronation. This is the body´s compensation in an effort to offset the "lose bag of bones" syndrome.
    • Decrease gravity drive pronation, Tibialis and Peroneus muscle activity decreases.
    • Decrease your gravity drive pronation, your feet will become more structurally stable.
    Some 50 years ago I published a paper on muscle leg and foot firing patterns. In plantar grade feet, these two muscles (Tibialis and Peroneus) were basically inactive during both swing and stance phase of gait.

    Incidentally, your proprioceptive insoles must be worn on both feet (even on the foot you feel is normal).


    Rothbart BA 1973. Phasic Activity of Muscles within the Lower Extremity. Journal Amer Pod Assoc, Vol 63(4), pp 129-137.
     
  31. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    80%, not 95%. The 95% came from a member on this forum. I believe it was Eric Fuller.
     
  32. efuller

    efuller MVP

    Brian I got that number from your 2002 paper. Maybe you should read it again. It's not worth my time to find the thread, here on the arena, where I first pointed this out to you, and you reread your paper and then admitted you were wrong.
     
  33. efuller

    efuller MVP

    Brian, reread my posts. I did not say the Van Langellan paper refuted Zitzelesperger. I said it refuted Elftman and Manter who were the ones who talked about converging axes. I was pointing out that it appears you have confused the Zitzelsperger paper with the writings of Elftman and Manter. The paper you cited had nothing to do with the writings of Elftman and Manter. Have you looked back at the Zitzelesperger paper to see that it did not talk about converging axes?

    The
     
  34. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Eric, I stand corrected. Elfman discussed converging axes, not Zitzlsperger.

    Both Zitzlsperger and Elfman research dealt with the investigation of the foot’s resiliency and stability during static and dynamic states. Each came to a different conclusion. I have found Elfman's conclusions most closely aligned to my research findings and clinical observations.
     
  35. scotfoot

    scotfoot Well-Known Member

    As a "senior researcher" Brian, have you ever been a named author in a randomized, controlled, trial. Your research seems to about all about your orthotics and, with the best will in the world , very prone to bias.
     
  36. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    The majority of my publications present my research which links gravity drive pronation to global postural distortional patterns. I have published several papers on my clinical findings regarding the pathology associated with these postural patterns. e.g., chronic, debilitating musculoskeletal and visceral pain. I have found that proprioceptive insoles are the most effective intervention in treating RFS or the PCFD. And have so mentioned it in some of my papers. However, my research is not all about these insoles.

    Regarding randomized, control studies, if my memory serves me correctly, I have published one or two single blind studies. But, IMO, the best way to prove or disprove my research is for other research teams to duplicate my protocols. To date only 3 independent research teams have done so (they have been referenced in other discussions on this forum).

    Quite frankly, I am surprised given the fact that my research has been accessed by over 21,000 readers resulting in 230 plus citations, 43 recommendations and an interest research score of 177.6 (ResearchGate)
     
  37. scotfoot

    scotfoot Well-Known Member

    Could you provide references to any randomized, controlled trials, where you have been named as an author? Thanks.

    So your research might well be wrong ,or right , you don't know? Would that not make your research generally speculative?
     
  38. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    You will find all my publications at https://www.researchgate.net/profile/Brian-Rothbart-2. You can peruse the papers and pick out the ones you are interested in.

    I have published statistical clinical studies, patient trials with outcomes, one year reevaluations and pressure plate studies. So, IMO, to call my research speculative is not appropriate.

    For example, In 1988 I published a study linking gravity drive pronation as a destabilizing factor in pelvic mechanics. At that time, many researchers questioned my outcomes. Since that time hundreds of papers have been published duplicating my findings.

    Another example, in 2014 I published a study linking gravity drive pronation to malocclusions. Again, at that time many researchers questioned my outcomes. Since that time many papers have been published validating this link.

    As far as my most recent research linking gravity drive pronation to alterations in brain wave activity, only time will tell if this study will be duplicated or not.
     
  39. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Actually, it was 2008 that I published a study in the JAPMA linking gravity drive pronation to distortions in the temporal bone and Class II malocclusion. The comments on this forum (Can Abnormal Pronation Change the Occlusion, 2012) were:

    "On which Planet" (childish and sarcastic)
    Kevin Kirby Reply 2

    "worth somewhat less than a puff of warm methane" (vulgar and unprofessional)
    Robertisaacs

    "totally discredited" (no love lost here)
    Craig Payne

    "I'll wait for the retarded spiders to come crawling out of the cracks to defend Brian's latest meritless proclamation." (trying to be clever, but failed)
    David Wedemeyer Reply 5

    "Will i ever see a patient with a problem in the head that i can treat as a podiatrist' ive never come across one in 30 years its like youre off with the fairys have you ever considered therapy you need help. (limited vision)
    fishpod 13

    12 years later, the link between the foot and occlusion is established by other research teams. Where has my fan club of Kevin, Robert, Craig, fishpod and David gone?
     
  40. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    That paper is now published. You can access it online, PositiveHealth January 2024, Issue 291
     
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